Main findings
This systematic review identified a total of seventeen published clinical trials examining nonpharmacological interventions (including exercise, psychoeducational interventions, physical therapy and drinking tea) on postpartum fatigue in postnatal women. Thirteen studies involving 1686 participants were included in the meta-analysis to examine the respective effectiveness of each type of intervention.
The findings of the meta-analysis suggest that exercise intervention significantly reduces symptoms of postpartum fatigue (SMD= -1.74, 95% CI=-2.61 to -0.88, Z = 3.94, P < 0.0001). This is consistent with the findings of previous studies[33, 34], which clarified the necessities and benefits of physical exercise for the overall health of postpartum women. A meta-analysis[35] indicated that postpartum exercise was beneficial for decreasing postpartum fatigue (SMD = 0.36). The benefits of exercise on fatigue are worth affirming. However, postpartum women are still at high risk for physical inactivity and rarely understand how to engage in postpartum exercise[33]. The American College of Obstetricians and Gynaecologists (ACOG) suggested that physical activity, including performing muscle-toning exercises, could be restarted 6 weeks after childbirth if the delivery was uncomplicated[36]. Daily 20 ~ 30 min of regular moderate-to-intense exercise is recommended[37]. A previous study reported that supervised postpartum exercise lasting more than eight weeks is suggested for reducing postpartum fatigue[14]. Therefore, clinical staff should give sufficient explanations and evidence-based instructions for postnatal exercises to help reduce women’s postpartum fatigue and facilitate their postpartum rehabilitation.
For depression, the results showed that there were no significant differences between the two groups (SMD=-0.05, 95% CI=-0.33 to 0.24, Z = 0.31, P = 0.75). This is inconsistent with the findings of a previous meta-analysis[38], which reported that exercise reduced symptoms of depression (SMD=-0.81, 95% CI=-1.53 to -0.10) of mothers who had been diagnosed with depression. The insignificant results may be explained by the fact that the two studies[12, 22] in our review did not include participants with obvious depressed symptoms at baseline. Therefore, a significant reduction in depression was difficult to observe after the exercise intervention. It is worth noting that in Yang et al.[12]’s study, women reported feelings of mood relaxation and pressure relief after the intervention, which indicated that exercise may have potential efficacy for women’s mental health. More research conducting exercise interventions among puerperae who have severe symptoms of psychological problems is needed to confirm the true effect of exercise on mothers’ psychological well-being.
Five studies performing psychoeducational interventions showed no obvious differences in postpartum fatigue and depression between the two groups at either the postintervention or 8-week follow-up. Although psychoeducational interventions usually involve various aspects associated with postnatal health, including fatigue, sleep, infection, nutrition, breastfeeding and so on, this type of intervention was mostly delivered via home visits, leaflet/booklets and home calls. It is difficult to guarantee the good compliance of participants due to a lack of sufficient supervision and guidance. Therefore, it may be difficult to perform psychoeducational interventions effectively. With the development of rapid electronic technology, people’s requests for health services have also facilitated instant communication and promoted efficiency in the transmission of information[39]. A previous study reported that web-based interventions had better effects on improving postnatal depression than home-based postnatal psychoeducational interventions[40] and suggested that web-based interventions should be introduced to mothers for better postnatal care. Hence, psychoeducational interventions could be combined with internet technology[41] or smartphones[42] in the future to improve the participation of women, observe the compliance of the participants and better manage the intervention implementation.
The findings from our meta-analysis of three studies[10, 11, 30] suggested that physical therapy was an effective treatment in relieving postpartum fatigue (SMD= -0.50, 95% CI=-0.96 to -0.03, Z = 2.09, P = 0.04). The intervention frequency of the included physical therapies ranged from 1 ~ 3 sessions. Each session lasted 10 ~ 30 minutes. These interventions were completed in 1 day. Physical therapies have the advantages of a short intervention time and good controllability. Warm showers, as a comfort measure, are closely associated with increased relaxation and tension reduction[43]. It is a safe and effective measure for healthy, labouring women who are experiencing physical and psychological issues[43]. The benefits of lavender oil on postpartum fatigue were reported in another RCT conducted among pregnant women[44]. Participants in either the lavender and footbath or lavender alone group showed that fatigue was improved significantly at 6 weeks postpartum. Although the efficacy of mother-infant skin-to-skin on fatigue was not observed in Funda et al.’s study, a recently published meta-analysis demonstrated that mother-infant skin-to-skin was a cost-effective, simple and feasible approach for postpartum depression[45]. Considering that physical therapies are relatively safe and effective, physical therapies such as footbaths[44], reflexology[46], warm showers[30] and lavender oil[11], which show effects on fatigue reduction and mental health improvement, could be used in combination to enhance the intervention efficacy. Among the three included studies, only Vaziri et al.’s study examined the efficacy of lavender oil aroma for psychological outcomes, including distress and mood, and positive effects were observed. More research is needed to explore its effectiveness for mental health.
In terms of drinking tea, the results showed that there were significant differences in postpartum fatigue between the two groups at postintervention (MD= -3.12, 95% CI=-5.44 to -0.80, Z = 2.64, P = 0.008), but no significant differences were found at the 2-week follow-up. The positive effects of drinking tea on relieving depression were obvious at the postintervention and 2-week follow-up. Postnatal women were required to smell (appreciate) the aroma before drinking the tea. Aromatherapy has been used for pain and anxiety relief, relaxation, and creating a pleasant feeling in mothers[47–49], which could help to relieve fatigue and depressive emotions. Women in the intervention group reported the benefits of drinking chamomile tea to be facilitating emotional stability and relaxation and having an aromatic fragrance, which could calm restlessness, facilitate the postnatal paternity relationship, and alleviate postpartum fatigue[50]. However, the positive effects did not last long after the intervention. Thus, multiple daily consumption of tea may be recommended to assess its lasting effect in consideration of its convenience.
Strengths and limitations
To the best of our knowledge, this is the first systematic review and meta-analysis on nonpharmacological interventions for reducing postpartum fatigue. This review was rigorous and based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statements as well as a prospective registered protocol. Another strength was that randomized controlled trials and controlled clinical trials were included in this review, which provides good standards for evidence-based research.
There were some limitations of this systematic review. First, a limitation of the review was that non-English electronic databases were not searched, which may cause language bias[51]. Second, the number of included studies for each type of intervention was small. The heterogeneity in the statistical combinations of exercise, psychoeducational intervention and physical therapy was significant. These factors may have an impact on the reliability of the pooled results. Third, a limitation lies in the risk of bias within the included studies. The potential biases may have influenced the reported effect estimates; therefore, caution is required when interpreting the findings of our study.